The overall aim of this thesis was to explore aspects of the subjective views and experiences of doctors as prescribers, focusing on responsibility for and factors of importance in achieving appropriate prescribing. To provide insights into the prescriber’s perspective the study designs were qualitative. In the first studies secondary care doctors’ perceptions of appropriate prescribing and influences in prescribing were investigated in interviews. The doctors perceived that appropriate prescribing needed continuous revision. From the perspective of the prescribers the definition of prescribing could be rephrased as: “the outcome of the recurring processes of decision making that maximises net individual health gains within society’s available resources”. Among the influences in prescribing were guidelines, colleagues and therapeutic traditions. In the subsequent studies the experiences of exchanging information regarding a patient’s drugs in an electronic patient medical record (e-PMR) shared between primary and secondary care and views of responsibility was explored, using focus groups with both primary and secondary care doctors. Considering the gap between health care levels, doctors’ views of responsibility in prescribing and exchange of information are of concern. The doctors expressed how they assume information to be in the e-PMR and active information transfer has decreased. On the other hand, they experienced an information overload in the e-PMR system. There is a need for improved and structured communication between health-care givers. Taking responsibility to review all the patient’s medications was perceived as important, but described as still not done. Lack of responsibility taken was often due to acts of omission, i.e. that doctors did not make needed changes to the list of medications due to different barriers. The barriers rested both with individual doctors and the system, but to ensure solutions that are realisable in practise, perspectives of the doctors need to be taken into consideration when overcoming those barriers.

Dissertation (Ph.D.)--University of South Florida, 2009. / Title from PDF of title page. Document formatted into pages; contains 123 pages. Includes vita. Includes bibliographical references.

Made available in DSpace on 2016-12-23T13:54:30Z (GMT). No. of bitstreams: 1 Regina Furbino Villefort Rocha.pdf: 5172514 bytes, checksum: a4a9d38bcac502c5c9c1fe6298995e29 (MD5) Previous issue date: 2012-07-04 / Ameloblastomas são tumores odontogênicos (TOs) de origem epitelial e etiologia desconhecida. Porém, estudos recentes identificaram alterações moleculares associadas ao desenvolvimento e progressão dos TOs, dentre elas as móleculas de adesão celular E-caderina e beta catenina. Objetivos: realizar um levantamento epidemiológico dos casos de ameloblastomas pertencentes ao arquivo do Serviço de Anatomia Patológica da Universidade Federal do Espírito Santo (SAPB-UFES), analisar suas características histopatológicas e a expressão de beta catenina nas diferentes variantes de ameloblastomas. Método: estudo retrospectivo dos casos de ameloblastomas registrados no SAPB-UFES, no período compreendido entre março de 2004 e dezembro de 2010. Foram coletados dados sociodemográficos, clinicorradiográficos, dados sobre acesso, diagnóstico, tratamento e seguimento desses pacientes. As análises histopatológicas foram baseadas nos critérios de Vickers e Gorlin, Waldron e El-Mofty e da Organização Mundial da Saúde. Para análise imuno-histoquímica foi utilizada a técnica indireta de imuno-peroxidase, com anticorpo primário anti beta catenina monoclonal de camundongo. Foram avaliados a intensidade e a localização da marcação. Para análise semiquantitativa foram adotados os escores: negativo, postividade focal, positividade variável e uniformidade positiva. Resultados: foram encontrados 13 ameloblastomas, classificados histopatologicamente como sólidos (06), unicísticos (03) e desmoplásicos (03). Todos foram imunomarcados. A intensidade de marcação variou de fraca a forte (1 a 3). A média de marcação variou de 10,82% a 13,38% no núcleo; de 39,93% a 47,61% na membrana; e de 90,01% a 98,53% no citoplasma. Entretanto não foi encontrada diferença significante de expressão de beta catenina entre os três diferentes tipos de ameloblastomas. Conclusão: os resultados epidemiológicos foram semelhantes a outros estudos. A expressão citoplasmática de beta catenina evidencia o acúmulo da mesma no citoplasma e sugere alteração na via de sinalização de Wnt. Por outro lado, a redução da expressão na membrana sugere alteração na adesão celular / Ameloblastomas are odontogenic tumors (OTs) derived from epithelium which etiology remains unknown. However, recent studies have identified molecular changes associated with the development and progression of OTs, including cell adhesion molecules like E-cadherin and beta-catenin. Objectives: to conduct an epidemiological investigation of ameloblastomas cases from files of the Anatomical Pathology Service at Federal University of Espírito Santo (SAPB-UFES), analyze their histopathological features and the expression of beta-catenin in different variants of ameloblastomas. Methods: a retrospective study of ameloblastomas registered at SAPB-UFES between March 2004 and December 2010. Sociodemographic, clinical and imaginological data were collected, as well as data about access, diagnosis, treatment and follow up of these patients. The histopathological analyzes were based on Vickers and Gorlin, Waldron and El-Mofty and the World Health Organization criteria. Primary antibody anti beta-catenin mouse monoclonal and indirect immuno-peroxidase technique was employed for immunohistochemical analysis. Intensity and location of the immunostaining were analysed. For semiquantitative analysis the scores were: negative, focal, variable and uniformity positivity. Results: there were 13 ameloblastomas, histopathologically classified as solid (06), unicystic (03) and desmoplastic (03). All of them were immunostained. The intensity of immunostaining ranged from weak to strong (1-3). The mean of immunostaining ranged from 10.82% to 13.38% in the nucleus; from 39.93% to 47.61% in the membrane; and from 90.01% to 98.53% in the cytoplasm. However, there was no significant difference in expression of beta-catenin between three different types of ameloblastomas. Conclusion: The results were similar to other epidemiological studies. The cytoplasmic expression of beta-catenin shows accumulation in the cytoplasm and suggests changes in the Wnt signaling pathway. Moreover, the reduction of membrane expression suggests changes in cell adhesion

Investigamos possíveis influências do programa Mais Médicos sobre os atributos de longitudinalidade e integralidade, considerando a estratégia de provimento de médicos nas equipes de Saúde da Família. Foi realizado um estudo de caso em dois municípios paulistas, a partir de abordagem etnográfica, entrevistas e grupos focais. Os resultados indicam efeitos positivos em relação ao atributo de longitudinalidade, com destaque para a boa relação dos médicos com usuários de saúde, acolhimento humanizado, criação de vínculo terapêutico, disponibilidade para realizar visitas domiciliares e apoiar a equipe no acompanhamento dos casos. A despeito dos médicos do programa reconhecerem a importância do princípio da integralidade, é restrita a contribuição dos mesmos ao alcance deste atributo, dado o excesso de atendimentos diários, conflitos de perspectivas com outros trabalhadores e limites da estrutura e modo de funcionamento da rede de saúde. Conclui-se que o provimento de médicos nas unidades de saúde contribui para o alcance da longitudinalidade, mas não garante atenção com integralidade, sendo necessário investir na formação contínua das equipes e na reorganização do trabalho / We investigated possible influences of the \"Mais Médicos\" program on the attributes of longitudinality and integrality, considering the strategy of providing doctors in Family Health teams. A case study was carried out in two São Paulo municipalities, based on an ethnographic approach, interviews and focus groups. The results indicate positive effects related to the longitudinality attribute, with emphasis on the good relationship of doctors with users, humanized care, creation of a therapeutic\'s bond, availability to perform home visits and support the team following-up cases. Although the program\'s doctors recognize the importance of the integrality principle, they have a limited contribution to the achievement of this attribute, given the excess of daily attendance, conflicts of perspectives with other workers and limits of the structure and organization of the health network\'s functioning. The conclusion is that the provision of physicians in the Family Health\'s team contributes to the achievement of longitudinality, but does not ensure attention with integrality, and it is necessary to invest in the continuous training of the teams and the reorganization of work

Made available in DSpace on 2014-08-20T13:58:01Z (GMT). No. of bitstreams: 1 Luiz_Artur_Rosa_Filho_dissertacao.rar: 315490 bytes, checksum: 32a8ba1b698ad8feb42d86b9324ef0bb (MD5) Previous issue date: 2006-11-07 / Aims: To study the prevalence of Interpersonal Continuity of Care (CIAS) and its socioeconomic and demographic determinants, as well as, those related to the health care and the persons health needs. Methods: It was developed a population-based cross-sectional study involving 3133 individuals of the urban area of Pelotas, RS. The studied sample included adults with 20 years or more and were selected in multiple steps. The multivariate analysis was performed trough Poisson regression. In the first level were the socioeconomic and demographic variables and in the proximal level were the health care and persons health needs. Results: The prevalence of CIAS was of 43,7% IC95% (42,0-45,5). Females, individuals with higher age, higher incomes, those who had consulted in the last year, those with chronic disease and the ones who had not consulted in the public health system had presented higher prevalence of CIAS. When analyzing those who had consulted in the Public Primary Health Care Services (UBS), females, older individuals and Family Health Program had higher prevalence of CIAS. Conclusion: The CIAS is more prevalent in the elderly and those with chronic illness. However, other vulnerable groups, as those with low income and users of the public health system, had low prevalence of CIAS, showing important iniquity in health. The Family Health Program seem to have positive impact in CIAS. / Objetivo: Estudar a prevalência de Continuidade Interpessoal na Atenção à Saúde (CIAS) e seus determinantes socioeconômicos, demográficos, assistenciais e relacionados às necessidades de saúde dos indivíduos. Metodologia: Foi realizado um estudo transversal de base populacional com 3133 indivíduos, moradores da zona urbana de Pelotas, RS. A amostra incluiu adultos com 20 anos ou mais e, foi selecionada em múltiplos estágios. A análise multivariável foi realizada através de regressão de Poisson, tendo no primeiro nível variáveis socioeconômicas e demográficas e no nível proximal, variáveis assistenciais e de necessidades em saúde. Resultados: A prevalência de CIAS foi de 43,7% IC95%(42,0-45,5). Indivíduos do sexo feminino, mais velhos, com maior renda, que consultaram no último ano, com relato de doença crônica e que não consultaram no sistema público de saúde apresentaram maior CIAS. Entre os que consultam em Unidades Básicas de Saúde(UBS), sexo feminino, aumento da idade e o Programa de Saúde da Família(PSF) estiveram associadas com CIAS. Discussão: A CIAS é mais prevalente em idosos e aqueles com doenças crônicas. Entretanto, outros grupos vulneráveis, como aqueles de baixa renda e usuários do sistema público de saúde, apresentaram menores prevalências de CIAS, o que mostra importante iniqüidade em saúde. O PSF parece ter um impacto positivo na CIAS.

La transition du patient entre les secteurs de soins est une période à haut risque de discontinuité de la prise en charge médicamenteuse. Les problèmes liés aux médicaments spécifiquement rencontrés résultent principalement de différences non expliquées entre les traitements médicamenteux documentés aux niveaux des différents sites de soins et/ou des différents professionnels de la santé, également appelés discordances médicamenteuses médicalement non justifiées. Leur survenue peut entrainer des préjudices pour le patient mais aussi une utilisation accrue des services de soins de santé et par conséquent une augmentation des coûts. <p><p>Dans ce contexte, la première partie de ce travail est consacrée à la mise au point d’un instrument valide et fiable permettant de caractériser les discordances médicamenteuses médicalement non justifiées lors de la sortie de l’hôpital. Il s’avère particulièrement bien approprié pour la recherche ou pour la familiarisation à la problématique. La deuxième partie de ce travail a permis de mettre en œuvre cet outil dans une situation clinique réelle. Une étude prospective d’observation incluant des patients recevant les soins usuels (groupe contrôle) et des patients pris en charge par des pharmaciens cliniciens (groupe intervention) a été réalisée. L’intervention des pharmaciens cliniciens comportait la réalisation d’une conciliation médicamenteuse à l’admission et à la sortie de l’hôpital. La conciliation médicamenteuse est un processus structuré pendant lequel le professionnel de santé collabore avec le patient, la famille et les proches pour s’assurer qu’une information correcte et exhaustive sur les médicaments est communiquée lors de la transition du patient entre les secteurs de soins. Elle consiste en la vérification (collecte d’un historique médicamenteux correct et l’identification des discordances médicamenteuses), la clarification (s’assurer que les médicaments et la posologie sont appropriés), la conciliation (documentation de chaque changement de médicament et éducation du patient à ce sujet) et finalement le transfert d’information aux autres professionnels de santé. Les résultats montrent que l’intervention des pharmaciens cliniciens diminue le risque de discordances médicamenteuses médicalement non justifiées après la sortie de l’hôpital. De plus, la satisfaction des patients vis à vis de l’information sur les médicaments prescrits à la sortie est significativement plus élevée dans le groupe pris en charge par le pharmacien clinicien. Cependant, aucun impact n’a été montré sur l’utilisation des services de soins (visites aux urgences et réadmission à l’hôpital) dans le mois après la sortie. Finalement, la dernière partie de ce travail a permis de développer une information sur les médicaments destinée aux pharmaciens d’officine à la sortie de l’hôpital du patient. Une étude prospective a évalué l’effet de la remise de cette information, dénommée feuille de transfert, par le pharmacien clinicien au patient. Une enquête en ligne ouverte à tous les pharmaciens d’officine a par ailleurs évalué leurs besoins en information. Il a été observé que la communication d’une feuille de transfert contenant des informations sur le traitement médicamenteux à la sortie de l’hôpital présente un réel intérêt pour le pharmacien d’officine. Ces informations vont en effet au-delà des informations retrouvées sur une prescription médicale. Néanmoins, la feuille de transfert devrait inclure davantage d'informations nécessaires pour la réalisation des soins pharmaceutiques. <p><p>En conclusion, ce travail a permis de développer, d’une part, un nouvel outil de détection et de classification des discordances médicamenteuses médicalement non justifiées et d’autre part, un modèle de pratique qui a montré son efficacité sur la continuité des traitements médicamenteux lors de la sortie des patients de l’hôpital à leur domicile, en maison de repos et en revalidation. Toutefois, des perspectives d’amélioration de ce modèle ont été mises en évidence et mériteraient une attention particulière dans le futur. / Doctorat en Sciences biomédicales et pharmaceutiques / info:eu-repo/semantics/nonPublished

O presente estudo teve como objetivo geral analisar as experiências dos profissionais de saúde da estratégia saúde da família (ESF) para o acompanhamento de crianças menores de cinco anos de idade com asma, na perspectiva do cuidado integral à saúde, fornecendo subsídios para a atenção primária em saúde da criança. Os objetivos específicos foram: descrever o perfil sociodemográfico dos profissionais na estratégia saúde da família nas unidades investigadas; descrever os sinais e sintomas, as medidas preventivas e promocionais e o tratamento relacionado à asma em crianças que os profissionais de saúde relatam na ESF; identificar e analisar as experiências dos profissionais de saúde no acompanhamento da saúde de crianças menores de cinco anos de idade com asma no contexto da ESF, na perspectiva do cuidado integral em saúde. Estudo descritivo e exploratório com análise qualitativa dos dados, desenvolvido em Ribeirão Preto-SP, em quatro unidades com ESF, selecionadas com base no número de crianças até cinco anos de idade cadastradas e em acompanhamento, a partir de dados do Sistema de Informação da Atenção Básica. Os participantes foram 25 profissionais de saúde (médicos, enfermeiros, auxiliares e técnicos de enfermagem e agentes comunitários de saúde), que estavam trabalhando nas unidades há pelo menos um ano, após aprovação em comitê de ética em pesquisa. Foram realizadas entrevistas semiestruturadas gravadas e individuais e a análise dos dados foi pautada na análise temática. Os resultados trazem aspectos relevantes sobre o acompanhamento da saúde da criança, destacando elementos da organização da assistência à criança na ESF, do tratamento medicamentoso e não medicamentoso, do seguimento especializado e das relações com a família no cuidado cotidiano da criança com asma. No cuidado em saúde o diálogo é fundamental, com construção da empatia, confiança, vínculo e co-responsabilidade entre os profissionais e as mães e famílias, buscando o alcance da adesão, um tratamento eficaz, a promoção da saúde e qualidade de vida da criança e sua família. Assim, são muito importantes as ações de promoção, prevenção, tratamento e reabilitação da saúde da criança, centradas na continuidade e integralidade da assistência. / This study aimed to analyze the experiences of health professionals from the Family Health Strategy (FHS) regarding the monitoring of children under five years old with asthma from the perspective of comprehensive health care, providing support for children\'s primary health care. The specific objectives were: to describe the sociodemographic profile of professionals in family health strategy in the units investigated; to describe the signs and symptoms, preventive and promotional measures and treatment related to asthma in children that health professionals report in the family health strategy; to identify and analyze the experiences of health professionals in monitoring the health of children under five years old with asthma in the context of the family health strategy from the perspective of comprehensive health care. This descriptive and exploratory study with qualitative data analysis was developed in the city of Ribeirão Preto, state of São Paulo, in four Family Health Strategy Units, selected based on the number of children under five years old registered and monitored from data Information System of Primary Care. Participants were 25 health professionals (physicians, nurses, nursing auxiliaries and technicians and community health workers) who were working in the units for at least one year, after the approval by the research ethics committee. Individual semi-structured interviews were conducted and recorded and data analysis was based on thematic analysis. The results bring up relevant issues on children\'s health, highlighting elements of the organization of health care in the FHS, of the drug and non-drug treatment, of the specialized follow-up, and of the relations with the family in the daily care of children with asthma. In health care the dialogue is essential in building empathy, trust, bonding and co-responsibility between professionals and mothers and families, aiming the adhesion, an effective treatment, the health promotion and quality of life of the children and their family. Thus, actions in health promotion, prevention, treatment and rehabilitation of child are very important, focusing on continuity and comprehensive care.

O presente estudo teve como objetivo geral analisar as experiências dos profissionais de saúde da estratégia saúde da família (ESF) para o acompanhamento de crianças menores de cinco anos de idade com asma, na perspectiva do cuidado integral à saúde, fornecendo subsídios para a atenção primária em saúde da criança. Os objetivos específicos foram: descrever o perfil sociodemográfico dos profissionais na estratégia saúde da família nas unidades investigadas; descrever os sinais e sintomas, as medidas preventivas e promocionais e o tratamento relacionado à asma em crianças que os profissionais de saúde relatam na ESF; identificar e analisar as experiências dos profissionais de saúde no acompanhamento da saúde de crianças menores de cinco anos de idade com asma no contexto da ESF, na perspectiva do cuidado integral em saúde. Estudo descritivo e exploratório com análise qualitativa dos dados, desenvolvido em Ribeirão Preto-SP, em quatro unidades com ESF, selecionadas com base no número de crianças até cinco anos de idade cadastradas e em acompanhamento, a partir de dados do Sistema de Informação da Atenção Básica. Os participantes foram 25 profissionais de saúde (médicos, enfermeiros, auxiliares e técnicos de enfermagem e agentes comunitários de saúde), que estavam trabalhando nas unidades há pelo menos um ano, após aprovação em comitê de ética em pesquisa. Foram realizadas entrevistas semiestruturadas gravadas e individuais e a análise dos dados foi pautada na análise temática. Os resultados trazem aspectos relevantes sobre o acompanhamento da saúde da criança, destacando elementos da organização da assistência à criança na ESF, do tratamento medicamentoso e não medicamentoso, do seguimento especializado e das relações com a família no cuidado cotidiano da criança com asma. No cuidado em saúde o diálogo é fundamental, com construção da empatia, confiança, vínculo e co-responsabilidade entre os profissionais e as mães e famílias, buscando o alcance da adesão, um tratamento eficaz, a promoção da saúde e qualidade de vida da criança e sua família. Assim, são muito importantes as ações de promoção, prevenção, tratamento e reabilitação da saúde da criança, centradas na continuidade e integralidade da assistência. / This study aimed to analyze the experiences of health professionals from the Family Health Strategy (FHS) regarding the monitoring of children under five years old with asthma from the perspective of comprehensive health care, providing support for children\'s primary health care. The specific objectives were: to describe the sociodemographic profile of professionals in family health strategy in the units investigated; to describe the signs and symptoms, preventive and promotional measures and treatment related to asthma in children that health professionals report in the family health strategy; to identify and analyze the experiences of health professionals in monitoring the health of children under five years old with asthma in the context of the family health strategy from the perspective of comprehensive health care. This descriptive and exploratory study with qualitative data analysis was developed in the city of Ribeirão Preto, state of São Paulo, in four Family Health Strategy Units, selected based on the number of children under five years old registered and monitored from data Information System of Primary Care. Participants were 25 health professionals (physicians, nurses, nursing auxiliaries and technicians and community health workers) who were working in the units for at least one year, after the approval by the research ethics committee. Individual semi-structured interviews were conducted and recorded and data analysis was based on thematic analysis. The results bring up relevant issues on children\'s health, highlighting elements of the organization of health care in the FHS, of the drug and non-drug treatment, of the specialized follow-up, and of the relations with the family in the daily care of children with asthma. In health care the dialogue is essential in building empathy, trust, bonding and co-responsibility between professionals and mothers and families, aiming the adhesion, an effective treatment, the health promotion and quality of life of the children and their family. Thus, actions in health promotion, prevention, treatment and rehabilitation of child are very important, focusing on continuity and comprehensive care.

Background: The purpose of drug treatment is to reduce morbidity and mortality, and to improve health-related quality of life. However, there are frequent problems associated with drug treatment, especially among the elderly. The aim of this thesis was to investigate the impact of clinical pharmacy services within a multiprofessional healthcare team on quality and safety of patients’ drug therapy, and to study the frequency and nature of medication history errors on admission to hospital. Methods: A model for clinical pharmacy services within a multiprofessional healthcare team (the Lund Integrated Medicines Management model, LIMM) was introduced in three hospital wards. On admission of patients to hospital, clinical pharmacists conducted medication reconciliation (i.e. identified the most accurate list of a patient’s current medications) to identify any errors in the hospital medication list. To identify, solve and prevent any other drug-related problems, the clinical pharmacists interviewed patients and performed medication reviews and monitoring of drug therapy. Drug-related problems were discussed within the multiprofessional team and the physicians adjusted the drug therapy as appropriate. Results: On admission to hospital, drug-related problems, such as low adherence to drug therapy and concerns about treatment, were identified. Different statistical approaches to present results from ordinal data on adherence and beliefs about medicines were suggested. Approximately half of the patients were affected by errors in the medication history at admission to hospital; patients who had many prescription drugs had a higher risk for errors. Medication reconciliation and review reduced the number of inappropriate medications and reduced drug-related hospital revisits. No impact on all-cause hospital revisits was demonstrated. Conclusion: Patients admitted to hospital are at high risk for being affected by medication history errors and there is a high potential to improve their drug therapy. By reducing medication history errors and improving medication appropriateness, clinical pharmacy services within a multiprofessional healthcare team improve the quality and safety of patients’ drug therapy. The impact of routine implementation of medication reconciliation and review on healthcare visits will need further evaluation; the results from this thesis suggest that drug-related hospital revisits could be reduced. / Läkemedelsgenomgångar och läkemedelsavstämning - LIMM-modellen